Medicaid Expansion Caps Supreme Court Arguments

Supporters of the health care law rally in front of the Supreme Court Wednesday, the final day of arguments over its constitutionality.

Charles DharapakAP

The last argument on the Affordable Care Act before the Supreme Court could have consequences far beyond health care.

The key issue is whether the health law's expansion of the Medicaid program for the poor unfairly compels the participation of states. Many considered this to be the weakest part of the states' challenge to the health law, and during Wednesday afternoon's arguments, that seemed to be the case.

"There was a lot skepticism about whether this is the line where it gets coercive," NPR's Julie Rovner told Ari Shapiro shortly after arguments ended.

The decision on this issue could affect the relationship between the federal government and the states. It's one of the few times the court has taken up what's known as the "spending clause" of the Constitution.

Federal and state governments split the cost of Medicaid. Wealthier states pay half. Less affluent states pay less.

Most, but not all of the costs added by the health overhaul law, would be born paid by the federal government.

Even so, some states say the expansion amounts to unconstitutional arm-twisting because they say they'd have to drop out of Medicaid altogether, if they don't go along.

Medicaid is voluntary, so the states could refuse.

But as Paul Clement told NPR before this week's historic arguments began:

"How any state at this point could say, 'We're just going to turn down Medicaid funding from the federal government' — I don't think any set of citizens would allow that to happen. Because it's all this money that's being taken from the state taxpayers that would then be going to every state in the union but that state; it just wouldn't work."

But he didn't get far with his argument Wednesday before he was challenged. According to The Wall Street Journal's Louise Radnofsky, Justice Elena Kagan asked, "Why is a big gift from the federal government a matter of coercion?" she asked. "It's just a boatload of federal money. It doesn't sound coercive to me, let me tell you."

After Clement finished his argument on behalf of the law's challengers, SCOTUSblog's Tom Goldstein wrote:

"The left is all over him for his argument against the expansion, but that is no surprise. The right was not critical, but it's too early to tell if there is actual support. That's next."

In a second update on the Medicaid extension, Goldstein wrote, "So far, it looks safe." And then after Clement had a rebuttal, Goldstein updated his analysis again, writing that "there were more voices ... for the idea that the Medicaid expansion is coercive, but it did not seem at all a likely outcome."

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